The imminent industry-association war over ICD-10

By Tom Sullivan
08:38 AM

Just as the seceding South Carolinians firing on the Union Ship “Star of the West” became recognized as the first shot in the Civil War, the American Medical Association’s delegates voting to vigorously oppose ICD-10 may one day be seen as the salvo that set a conflict over coding sets in motion. 

The stage is set for a war over U.S. adoption of ICD-10. Indeed, such a fight could pit industry associations that stand to profit from the code set against those representing the providers who have to actually implement and pay for the ICD-10 conversion.

Less than a week after AMA revealed the voting results, in fact, AHIMA CEO Lynn Thomas Gordon struck back with a public statement maintaining that “there are countless benefits that will come from the use of a 21st century classification system."

Then, the AMA’s second shot, a late-January letter calling on U.S. House Speaker John Boehner to block ICD-10, again drew fire from AHIMA, in the form of a warning that healthcare entities should continue keep proceeding with ICD-10.

Following that, on Thursday AMA sent another letter, this time to someone who definitely knew prior to receiving it what ICD-10 is, HHS Secretary Kathleen Sebelius.

Opposing forces
And so the divide between sides is perhaps stating to take shape. In one camp are the associations representing medical coders and, of course, selling certification, educational resources, training, and memberships to coders and those who employ them. While none have publicly joined AHIMA’s cause yet, the American Academy of Professional Coders (AAPC) did not firmly rule out such a tactic when asked.

“We are full steam ahead with ICD-10 and don’t anticipate any delays,” a spokesperson explained, then added “when we decide to make an official comment though, I’ll let you know for sure.” And pressed to clarify whether that “when” was carefully-crafted rather than an “if”, the spokesperson responded “that would be my assumption, but its the powers that be’s call. Sorry to be so vague, but that’s the stance as of today.”

On the other side of the battlefield, the AMA is led by president Peter Carmel, MD, who said that ICD-10 offers “no direct benefit to individual patient’s care,” rather, the conversion and code sets will “create significant burden on the practice of medicine.”

Much like the AHIMA-led band, AMA is thus far riding alone. But the American Hospital Association (AHA) and the Medical Group Management Association (MGMA) are in a similar position in that their constituency of physician practices and providers are the ones who will ultimately carry the costs and work of implementing ICD-10.

It’s too early to tell whether these other associations will become brothers-in-arms. MGMA senior policy advisor Robert Tennant, no proponent of ICD-10, told Government Health IT that the MGMA is in the process of charting its own strategy for ICD-10.

“We have consistently raised concerns and offered recommendations,” Tennant explained. “We are in the process of determining the best course of action from an advocacy perspective.”

Foot soldiers
The imminent war over ICD-10 will be fought between those who stand to profit in the near-term and those who represent the folks that will have to finance and implement ICD-10. And while it may be fought by the association generals, there are a host of tech vendors, coding service providers, foot soldiers, if you will, also taking up the fight.

Nick Dobrzelecki, CEO of Daymarck, a home healthcare coding specialist, breaks ICD-10 costs into three categories: training, productivity losses, and system changes.

“Any healthcare facility, such as a hospital, private practice, or home health care agency would incur costs for training, productivity losses and system changes,” Dobrzelecki says. “Because the elderly population continues to grow and therefore more healthcare professionals enter the field, delaying implementation will only increase these costs.”

Wellpoint vice president Andy Mader last week submitted a comment letter to HHS asking the agency to remove the .3 percent cap on ICD-10 within the Medical Loss Ratio provisions. Such a move would enable payers to treat the conversion as a quality improvement, rather than an administrative cost, a shift that would enable payers to include associated costs for changing medical office procedures, updating billing, administration and other relevant systems under the 80 or 85 percent of revenue they are required to spend under PPACA. “Pushing back deadlines would also help,” Mader added.

Unless, that is, ICD-10 is somehow blocked altogether, but it’s highly unlikely the AMA alone can accomplish that.

A trail all-too-familiar
Deborah Grider, senior manager of revenue cycle at accounting firm Blue and Co. and formerly the AAPC president and CEO, and an author of AMA-published ICD-10 books was having dinner with her editors at the AMA when news of the letter to Speaker Boehner came out.

“So we did talk about it and everybody is sitting on pins and needles waiting for something to happen, but the problem is every meeting I go to, every group I get in front of – I was at the Kentucky Medical Society a couple days ago speaking to a group of physicians – they bring up the letter, saying they feel the AMA is going to get ICD-10 stopped,” Grider explained. “My fear is that people are going to now lag behind and just sit and wait and it’s going to be late. In fact, AHIMA just came out with an article asking people not to wait and, you know, we’re out there in the industry trying to encourage them to get ready.”

Which is not to say that Blue has joined with AHIMA in any kind of official capacity, but lest the idea of allied industry associations seem far-fetched, Grider reminds that before ICD-10 was delayed until October 1, 2013, and during her time at the AAPC, “We banded together with others to try and delay ICD-10. Part of it was successful, we did get an additional couple years to implement. But I don’t think it will be pushed back much. If we are delayed, it will probably be 3-6 months and no more. If it’s 3-6 months and no more, well, there’s your breathing room right there.”

Given that ICD-10 has been postponed before, why the calls for either delaying it again or eliminating it altogether?

Perhaps because, even since the last deferment, very little has been done to gauge whether physicians actually can manage the transition in terms of cost, time, and resources.

Is ICD-10 even realistic?

That’s a question that was never properly answered. HHS has simply mandated that the industry do this, without effectively investigating whether or not transitioning to ICD-10 is even realistic for the small and mid-size providers who serve 74 percent of the whole population. ICD-10 challenges, however, are many and multi-faceted. Beyond training and implementation, they grow deeper and more complex, some with dire consequences: workforce, fraud, waste and abuse, sustainability, mitigation.

Edward Rippel, MD, of Quinnipiac Internal Medicine, P.C, who the NCQA unofficially calls its “triple crown winner” for achieving DRP, HSRP and PCMH as a solo practitioner, said that the top-down, federal mandate approach simply does not work.

“There are doctors saying that the cost of implementing ICD-10 across the country will be astronomical. It appears to be for the purposes of more accurate data capture on the part of individuals who want to do statistical analysis, but it’s coming on the backs of the doctors in terms of costs, workflow change and administrative problems,” Rippel said. “Once you start changing to a whole different coding system, providers will have to be re-educated on how to code for their services. It’s a universal system and they want to make everybody change – at our cost. In the end, who really benefits? Are the patients going to benefit from this? I don’t see it.”

Hold fire, for now
In the meantime, CMS remains steadfast that October 1, 2013 is a firm deadline and there will be no further delays. But with the healthcare industry currently in the middle of ICD-10’s EDI pre-cursor, HIPAA 5010, and its 90-day enforcement-free grace period, CMS has earned praise for being pragmatic enough to recognize the damage inflexibility might have wrought with 5010.

Just how well that transition is actually going, though, well that depends on whom you ask. While some would say that their advance preparation is already paying off, the fact is that claims are being rejected, be that due to payers being stricter than with 4010, extraneous information with 5010, taxonomy code requirements, or the number of procedure codes that necessitate a description, as ICD10Watch Editor Carl Natale reported last week.

Contending that the 5010 conversion “is not working and is choking the cash flow of many of its members,” MGMA last Wednesday called on HHS Secretary Sebelius to not only extend the HIPAA 5010 enforcement-free period until June 30, during which covered entities could submit 4010 claims, but also instruct MACs to provide advance payments to physician practices having difficulty with 5010, allow MACs to accept claims that do not include all the requisite 5010 data, expedite adjudication of paper and electronic claims, monitor readiness level in the industry, among others. 

“One thing we are watching for is the industry transition to HIPAA 5010,” MGMA’s Tennant explained. “Smooth or protracted implementation of 5010 will be a good gauge for how ICD-10 will go.”

Whether the AMA gains allies against AHIMA or falters alone like John Brown’s band at Harper’s Ferry (though with less dire circumstances) remains to be seen, of course.

But last week’s ICD-10 skirmish will not likely be the end of anything.